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1 The presentation will begin shortly. The content provided herein is provided for informational purposes only. The views expressed by any individual presenter are solely their own, and not necessarily the views of HRET. This content is made available on an AS IS basis, and HRET disclaims all warranties including, but not limited to, warranties of merchantability, fitness for a particular purpose, title and non-infringement. No advice or information provided by any presenter shall create any warranty Silver Award Recipient

2 Building the Science of Public Reporting Brent Sandmeyer, MPH Agency for Healthcare Research & Quality September 16, 2016

3 Public Reporting: A Key Strategy in Achieving High Value Health Care ACA, NQS, NAM identify public reporting as foundational infrastructure for improving care and lowering costs. Transparency of process, outcome, price, and cost information, both within health care and with patients and the public, has untapped potential to support continuous learning and improvement in patient experience, outcomes, and cost and the delivery of high-value care Smith et al, eds. (2012). Best Care at Lower Cost: the Path to Continuously Learning Health Care in America. Institute of Medicine.

4 Building the Science : AHRQ & CMS fund 17 studies to improve the design, dissemination, and underlying measures and methods of public reports. Studies address many areas of care (e.g. hospitals, home health, nursing homes, surgery), with a focus on vulnerable populations. Summaries available here:

5 Decision Points Consumer engagement in making health care decisions may be higher for: Shoppable care (maternity, nursing home) Disruptions (moving, job or insurance change) Bad experiences (medical errors, arguments) 1 1. Shaller, Kanouse, Schlesinger (2014). Context-based Strategies for Engaging Consumers with Public Reports about Health Care Providers. Medical Care Research & Review.

6 USING STAR RATINGS IN NURSING HOMES : A QUANTITATIVE AND QUALITATIVE EVALUATION Rachel Werner, MD, PhD With: Tamara Konetzka PhD, Dan Polsky PhD, Judy Shea PhD, Marilyn Schapira MD Funded by the Agency for Healthcare Research and Quality (R21-HS021861)

7 Background: Nursing Home Compare In 2002: CMS began publicly rating nursing homes on 10 individual measures of clinical quality Staffing Deficiencies In 2008: CMS converted to a 5-star rating system Overall star rating Star ratings for clinical quality, staffing, deficiencies Underlying individual measures still available

8 Example of the 5-star report card

9 Question #1: Is there a change in admission rates to nursing homes following summary ratings in 2008? Are consumers more likely to choose a 5-star facility than a 1-star facility after star ratings were released? If so, presumably consumers (or their agents) use star ratings when using a nursing home

10 What we do Test for changes in choice of NH as a function of star ratings Pre-post design ( vs ) Estimate whether a patient s choice of nursing home as a function of The nursing home s 5-star rating Whether the admission occurred after the star ratings were available (post- December 2008) The interaction between the two Also control for other nursing home characteristics and the driving distance between home and each nursing home option

11 Data OSCAR (2005 to 2010) All Medicare/Medicaid-certified nursing homes Inspection and staffing ratings Facility characteristics Profit status, # beds, chain, hospital based, occupancy, % Medicare, % Medicaid We include all nursing homes included in public reporting 16,147 nursing homes Minimum Data Set (2005 to 2010) All nursing home admissions Detailed clinical data collected at regular intervals Replicate the quality score for Nursing Home Compare We include a 20% random sample of admissions between ,316,649 nursing home admissions

12 Admissions by star ratings

13 Adjusted changes in admissions by star ratings All admissions Post-acute care Long-term care Post 2008*2-star 0.023*** 0.024*** 0.03* Post 2008*3-star 0.018*** 0.019*** Post 2008*4-star 0.017*** 0.021*** ** Post 2008*5-star 0.079*** 0.082*** 0.085*** N 181,148, ,741,202 15,406,835 Covariates: driving distance, profit status, number of beds, occupancy rate, % Medicaid, % Medicare

14 How large is the change in admissions? Simulated market with 5 nursing homes Pre-2008 market share Post-2008 market share Absolute change Relative change 1 star % 2 star % 3 star % 4 star % 5 star %

15 How large is the change in admissions? 1 SD improvement in % in pain (2002) 66% to 86% 1 SD improvement in star rating (2008) 3 to 5 stars Absolute change in market share in an average market

16 Question #2: Do consumers tradeoff between summary and individual ratings? Conduct in-depth, structured interviews Convenience sample of persons (or caregiver) recently admitted to a nursing home or anticipating nursing home admission Assess salience and use of nursing home rankings including star ratings and individual quality measures 35 interviews 23% high school education or less 29% black 51% urban

17 What we found Few participants used NHC when choosing a nursing home Liked and understood the star ratings Some confusion over how the stars were calculated, particularly when the overall star didn t appear to be an average of the staffing, deficiencies, and quality measure stars Generated some distrust

18 What we found Most also liked the individual quality measures Some confusion high scores indicate higher quality in some and worse quality in others Most naturally focused in on the quality measures that were most salient to them About 1/3 reported using the star ratings to narrow the choices and the individual measures to choose 20% reported that there was too much information Concentrated among low SES subjects Most reported the report cards were missing information that was important in their decision Resident/caregiver ratings

19 Conclusions Converting to a summary nursing home quality measure resulted in a relatively large change in consumer demand Further improvements in the summary measure could increase its effect Summary measures are a complement to, not a substitute for more detailed quality information

20 No one size fits all reporting Consumer Views of Maternity Care Quality Maureen Maurer, MPH Principal Researcher American Institutes for Research September 16, 2016 Copyright 20XX American Institutes for Research. All rights reserved.

21 Objectives Today Explore factors that influence the use of public reports for hospital maternity care quality, focusing on: Women s perception and definition of maternity care Information about maternity care quality that women value Women s awareness of current maternity care quality efforts and measures Discuss implications for public reporting efforts 21

22 What did we do? The context: study to test a new approach to attract pregnant women to a hospital-level maternity care quality website Conducted focus groups to get input on website development Conducted baseline survey for randomized trial 22

23 What did we explore? Focus groups with women who were currently pregnant, planning to get pregnant or had given birth in the past year, focusing on: How women describe high quality maternity care Relative importance of different quality measures How and when quality information would be used Baseline survey of 245 women in North Carolina who were 8-30 weeks pregnant Factors important in choosing a hospital Awareness of comparative quality information 23

24 What quality measures did we discuss? Quality Measure Focus Groups Survey Incidence of episiotomy X X Appropriate newborn bilirubin screening prior to discharge X X Exclusive breast milk feeding in the hospital X X Early elective delivery (before 39 weeks) X X Appropriate deep venous thrombosis (DVT) prophylaxis in women undergoing C-section Use of antenatal steroids for babies at risk of delivering before 34 weeks X X X X First-time, low risk C-section Use of prophylactic antibiotics received within one hour prior to surgical incision C-section Health care associated bloodstream infections in newborns X X X 24

25 What did we learn? Focus groups High quality maternity care focused predominantly on interactions with providers Individualized care Effective communication Coordinated care Roles & responsibilities Women = be informed, ask questions, voice preferences Doctor = decides if intervention is medical necessary Hospital = not perceived as having a large role 25

26 What did we learn? Focus groups Most interested in measures: Related to babies health Clearly the hospital s responsibility Part of standard care that should happen for all patients Would use quality information to: Choose provider, if early enough Talk to doctor about quality of care 26

27 What did we learn? Baseline survey: Important Factors 27

28 What did we find? Baseline survey: Awareness 28

29 What does this mean for public reporting efforts? Important context for public reports Women are highly motivated to seek information on maternity care quality Women have limited awareness of quality measures Women have limited understanding of hospital role in ensuring quality Pregnancy, labor, and delivery are emotionally charged 29

30 What does this mean for public reporting efforts? Relevance of quality measures Most important associated with babies health (but they were not available for our larger study) Communication and respect important (but current measures are not maternity care specific) Hospital level reporting available (but women want physician level reporting) Insurance and cost an important factor (but we did not have access to information about cost to individuals) 30

31 What does this mean for public reporting efforts? Short-term: Create connections between current measures and what women are interested in Clarify role of hospital in ensuring quality Test how to frame and label measures to increase understanding and reduce bias Expand how we think about using public reports (to inform care decisions, not just provider selection) Long-term: Develop publicly available measures that most closely relate to women s needs across care settings (physician, hospital) 31

32 Contact information: Maureen Maurer Center for Patient and Consumer Engagement 32

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